Cancer concentrates the mind, but fertility isn’t your first thought when you receive a diagnosis. It is such an overwhelming time: you are at the complete mercy of your medical team and you want to protect the people closest to you. Your survival is paramount and it may only be on reflection, at a later date, that the importance of fertility can become something of a priority.

When you are diagnosed with cancer at a relatively young age, fertility is most likely going to be an issue. Whether due to surgery or another treatment, it will have an impact one way or another.

MY STORY

I was diagnosed with breast cancer in 2012 at the age of 36. I underwent chemotherapy, a mastectomy and a course of radiation. I was then put on the oestrogen inhibitor tamoxifen, which sent me into menopause by the time I was 38. In 2017, my cancer metastasised into my bones and lymph nodes but, after a successful course of immunotherapy and lifestyle changes, I am now one of those lucky ones ‘living with cancer’. I had children before my cancer diagnosis, but fertility was never addressed with me during my initial treatment. I was never asked if I had children or if I even wanted children, or if I wanted more children. I feel that the doctor didn’t see it as a priority, which I can understand. But, after coaching others in the course of my voluntary work with a local cancer support network, it is very clear the loss of fertility can have huge impact on patients. We put our trust in our medical teams, but that leads to a loss of control on the patient’s part, which can have huge repercussions.

FERTILITY: AN OVERLOOKED ISSUE

Eight years down the line of treatment, and after supporting many clients through my voluntary work, it’s clear that the issue of fertility is something that is often overlooked or deemed unimportant at the time of diagnosis and treatment. Even when I did go through a period of serious reflection later on in my treatment, wishing I could have more children, it was a ‘fait accompli’ and I had to move on. I never talked to anyone, even my family and friends, about it. I am not alone in experiencing this. Only in recent months have I taken back a modicum of control and know when to ask the right questions and with whom to consult.

Cancer is wily and affects your life in many different ways, physically and psychologically. It is the silent, unseen psychological effects that are often overlooked and I would counsel anyone going through this difficult time to seek support, no matter how well they think they are doing. Not so long ago, it was enough to succeed in getting someone to stay alive for longer, but now we encounter people who are more likely to survive, and live a long time  after cancer. Also, more and more people are living quite normal lives with cancer, which is a relatively new concept to be addressed.

MAKING THE DISCUSSION A PRIORITY

I know that fertility treatment is constantly evolving. But I believe that a medical team have a responsibility to address the issue with a patient as early as possible during diagnosis and treatment, in order for the patient to have time to process whether it is going to be a priority or not.

It goes without saying that a patient is overwhelmed by the information being thrust at them at this difficult time, but doctors need to give their patients a certain level of trust, to realise that they have the right to decide the importance of fertility in their future. I believe that a doctor has the responsibility to ‘plant the seed’ early on.

There is no need to overwhelm a newly diagnosed patient with all the options, as I know that it is an expert field. But ‘forewarned is forearmed’ and the right information could prevent a lot of problems down the line.  We tend to deal with the fallout from cancer on a reactive basis, rather than having the information in advance.

Hopes and dreams are constantly changing, especially after a cancer diagnosis. Those who did not ever want children may suddenly long for them. They may divorce, remarry or want more children, or face many other life issues that we are presented with as human beings. What someone feels at 28 may be very different to what they may feel at 38 or 48.

A patient/person deserves to be provided with the information that they need to make a considered decision.

CAROLINE MASLIN

 

COMMENTARY

Caroline’s elegant description raises many of the major issues underlying the provision of  fertility preservation. Women with breast cancer constitute the largest diagnostic group facing fertility-damaging treatment, and those with hormone-sensitive disease have the additional issue of adjuvant endocrine treatment, with ovarian suppression for 5–10 years thereafter.

Not all women will lose their fertility with cancer treatment, but the overall reduction in the chance of a post-treatment pregnancy for women aged under 40 is 38% across all diagnoses. For women with breast cancer, the hazard ratio for achieving a first pregnancy after treatment is 0.30.¹ The need to address this issue with cancer patients before treatment starts was highlighted by NICE guidelines in 2013.² The most relevant medical procedure, oocyte vitrification after ovarian stimulation, is now well established, although funding for adequate provision is a major challenge.

Effective care requires rapid lines of communication between oncology and reproductive medicine centres, as time will be of the essence, and challenges the need for adequate information provision. Online decision aids (e.g. www.cancerfertilityandme.org.uk) may help here.

New quicker protocols for ovarian stimulation have been developed based on a ‘random start’, rather than being limited to specific stages of the menstrual cycle. Data on outcomes are limited; while there are emerging data that oocyte quality may be slightly reduced in women with cancer, good live birth rates can be achieved.³

Caroline also raises the wish of many women who already have children to have more after diagnosis – the natural desire to complete their family. This contrasts sharply with NHS-funded assisted reproduction, which limits treatment to a first child.

RICHARD ANDERSON
MRC Centre for Reproductive Health, University of Edinburgh

REFERENCES

1. Anderson RA et al. 2018 Human Reproduction 33 1281–1290.
2. NICE 2013 Fertility Problems: Assessment & Treatment CG156 www.nice.org.uk/guidance/cg156.
3. Cobo A et al. 2018 Human Reproduction 33 2222–2231.